Usrc Oneida Dialysis

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 32908 Based on document review, observation and interview, in 1 of 11 observations, dialysis unit staff did not perform hand hygiene and use gloves as required. This places patients and staff at risk for potential infection. Findings include: -- Per review of the dialysis unit’s policy and procedure titled “Hand Hygiene,” revised 8/2020, indicated “hand hygiene consists of either handwashing with soap and water or use of an alcohol-based formulation. Hand Hygiene should be performed ... after touching patient surroundings (e.g., dialysis machine, any items in the dialysis area or chairside computers ... “ -- Per observation on 8/13/2024 at 10:55 am, Staff A, Registered Nurse, addressed a dialysis machine alarm ringing at Station #1 while wearing gloves. Staff A then went to address another alarm ringing at Station #5 without changing gloves and performing hand hygiene. He/she/they acknowledged this finding at the time of observation.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 32908 Based on document review, observation, and interview, (1) in 4 of 4 observations, dialysis unit staff did not clean and disinfect the patient scale between uses, did not clean and disinfect the surface of the chair after patient’s placed their personal items on while using the scale, and did not clean and disinfect the hand held thermometer used to scan patient’s temperatures post treatment. (2) In 3 of 3 observations, dialysis unit staff did not clean and disinfect their stethoscope used to auscultate patient’s heart and lungs between patients. This places patients and staff at risk for potential exposure to infections. Findings related to (1) include: -- Review of the dialysis unit’s policy and procedure titled “Disinfection and Cleaning of Dialysis Machine Equipment,” revised 7/2023, indicated “the purpose is to provide guidance on proper disinfection of the dialysis station, machine, equipment, and surrounding surfaces with the appropriate method prevents the transmission of disease/infection to the dialysis population. Clean ancillary equipment ... “ -- Per observation on 8/13/2024 at 10:00 am, 10:35 am, and 10:55 am, Staff A, Registered Nurse, did not clean and disinfect the handrail of the scale after obtaining a patient’s post treatment weight, the chair the patient used to place their personal belongings on, or the thermometer used to scan a patient’s temperature post-treatment. Additionally, cleaning/disinfecting wipes were not available in the post-treament area. Staff A stated these items are not cleaned and disinfected between patients and confirmed the above findings at the time of observation. -- Per observation on 8/14/2024 at 10:35 am, Staff B, Licensed Practical Nurse, did not clean and disinfect the handrails of the scale after obtaining a patient’s post treatment weight, the chair the patient used to place their personal belongings on, or the thermometer used to scan a patient’s temperature post treatment. Additionally, there were not any cleaning/disinfecting wipes (Day 2 of the survey) in the area (post-treatment) of the scale, chair, and thermometer. -- During interview of Staff C, Facility Administrator on 8/14/2024 at 2:15 pm, he/she/they acknowledged the above findings. Findings related to (2) include: -- Review of the dialysis unit’s policy and procedure titled “Disinfection and Cleaning of Dialysis Machine Equipment,” revised 7/2023, indicated to disinfect non-disposable medical equipment. -- Per observation on 8/13/2024 at 10:55 am, Staff A did not clean and disinfect his/her/their stethoscope between patients after auscultating their heart and lungs at Stations #1, #5, and #8. Staff A confirmed the findings at the time of observation.”

“PR-RIGHTS POSTED,STATE/NW ONTACT INFO CFR(s): 494.70(c) The dialysis facility must prominently display a copy of the patient’s rights in the facility, including the current State agency and ESRD network mailing addresses and telephone complaint numbers, where it can be easily seen and read by patients. This Standard is not met as evidenced by: 32908 Based on observation, interview, and document review, the dialysis facility lacked posted signage in the in-center and home dialysis waiting rooms with the contact information for filing a grievance with the End Stage Renal Disease (ESRD) Network and New York State Department of Health (NYSDOH). This could lead to patients not being informed of their rights. Findings include: -- Per observation on 8/13/2024 at 8:50 am, the in-center and home dialysis waiting rooms lacked posted signage for patient rights contact information for filing a grievance with the ESRD Network and NYSDOH. Staff C, Facility Administrator, acknowledged the finding at the time of observation. -- Per review of the dialysis unit’s policy and procedure titled “Patient Rights and Responsibilities,” revised 2/2023, it indicated information to be posted includes the list of patients’ rights, the mailing address, complaint telephone numbers, and contact information for the applicable ESRD Network and the state/federal/accreditation survey agencies, as well as the U.S. (United States) Department of Health and Human Services Office for Civil Rights.”

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 46619 Based on document review and interview, the facility did not complete mortality reviews in 3 of 3 patient deaths. This may place patients at increased risk of harm. Findings include: -- Per review of the facility’s policy and procedure titled “Mortality Review,” last revised 10/2023, “facilities must perform a comprehensive review of individual and aggregate data and trending of causes of patient deaths and the relationship to the care received at the facility. This review will include cause(s) of patient deaths, contributing factors, and the relationship to the care received at the facility. The mortality review form should be completed for each patient death within thirty days and will be reviewed at the next Quality Assurance and Performance Improvement Committee meeting. The mortality root cause tool will be used to track and trend root causes for patient deaths and will also be discussed at monthly meetings. If trends relating to care provided by the facility are identified, actions to address the identified root cause(s) will be taken.” -- Per interview of Staff D, Medical Director, on 8/14/2024 at 1:15 pm, he/she/they only complete mortality reviews when the facility administrator provides them for completion. Staff D acknowledged these findings. -- Per interview of Staff C, Facility Administrator, on 8/14/2024 at 2:00 pm, there have been 3 patient deaths in the last 6 months. Staff C acknowledged that he/she/they were not aware of the requirement to conduct these reviews in collaboration with the provider and to include discussion within their Quality Assurance and Performance Improvement Committee meetings.”